Recent personal experiences have opened my eyes to how similar the behavior of individuals in severe, chronic pain can be to that of people in the throes of severe substance use disorders (SUD) when they can’t get their drug of choice.
In other words, severe pain and substance use disorders can make you feel desperate and driven to get what you need for relief.
Is it "Doctor Shopping" or Chronic Pain?
Certainly, there’s concern when a SUD is so consuming that an individual “doctor shops,” trying to get one or more prescription medications to get high. But it’s not uncommon for someone in acute or chronic pain to be put in the same position and to act the same way to get alleviation of pain.
However, if you have a history of a substance use disorder, even if it’s in remission and/or even if painkillers were not your drug of choice, it’s likely that you’ll have difficulty finding a physician to prescribe opioids. One of my relatives has a chronic medical condition caused by an alcohol use disorder that’s been in remission for nearly 9 months. The pain caused by the condition has been likened to that of childbirth, and the relative has been bedridden with it much of the past several months. The national society representing this person’s condition recommends opioids for acute and chronic pain when less strong pain relievers don’t work, which has been the case with my relative. The person has never enjoyed opioid painkillers in large part because they cause unpleasant allergic-type reactions (severe itching, nausea, and vomiting) but a few can be tolerated with lesser side effects in order to get pain relief.
Several local physicians have given the relative short-term prescriptions for the pain, but then cut them off although the pain has not been resolved and despite having an appointment in several weeks at a world-renowned clinic for the disorder in several weeks. (A specialist at a nearby pain clinic who hadn’t even seen the person said that opioids would not be an option, and another doctor said even the mildest of opioids “could be a slippery slope.”) Thus, the suffering continues.
8 Ways to Get Labeled a “Pain Pill Seeker” When You Aren't One
While watching a loved one go through this and through my work, I’ve learned the following lessons about how people become labeled “painkiller seekers,” even when they’re not:
- Ask for painkillers when you have a history of any type of substance use disorder. When the doctor says “no” because of your addiction history, argue that painkillers have never been a problem for you. The truth is, according to renowned addiction physician, Mark Willenbring, M.D., director of Alltyr Clinic in St. Paul, MN and formerly with the National Institutes of Health, “The neuroadaptations in the brain that result from the combination of genetic vulnerability and environmental triggers are substance-specific. That is, the dysregulation of consumption of the intoxicant only applies to the specific drug consumed. It does not apply to other drugs. In my practice, I find that opioid addicts seldom like alcohol, and vice versa.” (For more, see his Pro Talk column about the brain and addiction.)
- Look like you’re sick and tired when you go to the doctor’s office or emergency room. My relative was told by a nurse in family practice, “I can tell you right now that if you go to the E.R. the way you’re looking, you’re not going to get any help. My relative said, “You mean, looking sick? Should I go home and put on makeup and then go to the ER?” Jeffery Junig, MD, PhD, an addiction psychiatrist in solo private practice in Fond Du Lac, Wisconsin and Assistant Clinical Professor of Psychiatry, Medical College of Wisconsin, said, “People face ‘opioid discrimination’ not only for their medical histories, but also for tattoos, haircuts, or muscle-shirts. [I’ll add piercings to the list.] Over the years I’ve met many severe opioid addicts who looked like businesspersons or professionals, who were given 60 oxycodone tablets for a backache. Yet I’ve had patients who were stable in their recovery from opioid use disorders who received only ibuprofen for kidney stones.”
- Act like you’re not sick enough – and don’t even think about cracking a joke. That same nurse told my loved one that she didn’t seem like she was in enough pain to get emergency help. People who live with chronic pain can tolerate more pain than normal people and can often come across as being more composed than they feel.
- Lose your temper – especially when you’ve been treated with disrespect. That obviously means you’re a “druggie.”
- Act like you’re very much in need of painkillers. One health care professional outright told us that if you seem too desperate, it’s a red flag that you might have an addiction problem (even if you don’t.)
- Go to more than one health care provider at the same medical facility and ask for help. But what’s a person to do when one doctor doesn’t believe in giving out painkillers or another cuts you off for no apparent reason and you’re still in pain?
- Have a mental health disorder that causes you to be emotionally dysregulated, especially when you’ve been experiencing chronic pain. Medical professionals might say it’s all or partly in your head. Of course a vicious cycle becomes created as the dysregulation becomes worse and the pain worsens – or vomiting from your pain or illness makes it hard to keep your psych meds down.
- Be very specific about the painkiller you want, especially if you’ve been offered one or more that you know you can’t tolerate or won’t work for you. That suggests you’re looking for your “drug of choice.”
How Opioid Hysteria is Hurting People
“So many people are suffering needlessly because of the hysteria about opioids – we’ve gone too far the other way in making it so difficult for those who need pain relief to get opioid painkillers. The suicide rate is likely to be high in individuals with chronic pain.”
Junig agreed that, although we clearly had a problem in this country with the over-prescription of opioids, things have swung so far in the other direction that doctors are routinely cutting people off pain medications, throwing patients into withdrawal, which leads many of them to illicit opioids and even heroin. He added:
“Opioids and their actions are some of medicine’s greatest discoveries, and they can be used safely with appropriate precautions. And people with history of opioid dependence have the same right to pain relief as any other patient.”
His main issue is this:
“Many of the anti-opioid doctors try to distinguish between ‘acute pain’ and ‘chronic pain’. You’ll often hear comments that opioids are appropriate for ACUTE pain – for instance, after surgery or broken bones – but should not be used for CHRONIC pain, as if the suffering is somehow less severe or less-worthy of treating for those with chronic pain. But what if the pain is actually JUST AS BAD in the chronic patient as it is in the acute pain patient? What if the severity is the same?”
Junig said that he has a patient whose chronic pain is so intense that tears roll down his face every few minutes, when he is struck by paroxysms of phantom-limb pain. He even had an implant in his brain to try to control it, but the implant only causes him to have seizures and doesn’t reduce the pain.
“Many docs would call him a ‘chronic pain patient,’” Junig said, “even though his pain is at least as severe as a person coming out of major surgery.”
Choosing Your Health Care Professional(s) Wisely
I asked Dr. Willenbring if I was wrong to be disinclined to advise people in recovery to be very careful and selective about giving out information about a past history of addiction to medical providers. He replied:
"I tend to agree with you. However, it's getting more difficult over time, with the electronic medical record, to not have information about an addiction history revealed. Few people understand that when they sign an informed consent to establish care, there's usually a provision in there to allow access to a patient's full prescription history, whether it was provided by someone else or not. (That provision in the informed consent document can be struck if the patient crosses it out and initials it, but I believe that some systems still can tap into outside prescription history.)"
“Also, pharmacists already have access to that. So if someone has ever been prescribed Naltrexone, for example, or Suboxone, then that would make it clear that they have an addiction history. Another way that your history can come out is if a spouse or other relative, such as an adult child, sibling, or parent, interact with the provider. The risk is that if the addiction history is somehow found out after the fact, then the health professionals might regard that as deception and an attempt to manipulate for controlled medications. Obviously, this is a double bind, so one would have to weigh how likely it is that a provider will learn about an addiction history in some way other than directly from the patient."
Jim Carter, Ph.D., a San Diego clinical psychologist who specializes in behavioral health, said:
“‘Pill seeker’ is a ridiculous label. All patients seeking treatments from MDs are either ‘pill seekers’ or ‘surgery seekers.’ What else would the patient seek? I would encourage any patient (with or without a history of SUD) seeking opioid medication treatment to proceed with caution and carefully select a provider whom the patient can trust enough to openly discuss the potential risks and benefits.”
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